Medical brain notes 42

  Premenstrual Syndrome and Premenstrual Dysphoric Disorder Premenstrual syndrome (PMS)  is a group of physi- P  cal, mood-related, and behavioral changes that occurin a regular, cyclic relationship to the luteal phase of the menstrual cycle and that interfere with some aspect of the  patient’s life.  These symptoms occur in most cycles, resolv-ing usually with onset of menses, but certainly by cessa-tion of menses. This cyclic symptom complex varies both in severity and in the degree of disruption of the patient’s work, home, or leisure life. The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV),  liststhe diagnostic criteria for  premenstrual dysphoric disorder(PMDD)  as a specific set of at least 5 of 11 possible symptoms,with at least 1 core symptom—specifically depressed mood, anxiety or tension, irritability, or decreased interest in activities (anhe-donia).  These symptoms occur regularly during the lutealphas...

  INCIDENCE   Premenstrual symptoms occur in approximately 75% to 85% of women.  PMS that causes significant disruption of dailylife occurs in approximately 5% to 10% of women. PMDD, rig-orously diagnosed as outlined in the DSM-IV, affects only 3% to 5% of women.  PMS and PMDD can begin with menar-che, but can also present later in life, even in a woman’s 40s, though this is often a reflection of the hesitancy of women to seek medical help for their symptoms. The expression or symptom dominance of these disorders dif-fers depending on ethnicity and culture. There is some evidence that the incidence of PMDD varies across cul-tures as well, with high rates in Mediterranean cultures and the Middle East and low rates in Asia. Twin studies also demonstrate concordance, implying a genetic contri-bution to the development of these disorders.

  SYMPTOMS   Over 200 symptoms have been attributed to PMS. Each patient presents with her own constellation of symptoms, thus making specific symptoms less important than the cyclic occurrence of the symptoms. Somatic symptoms that are most common include abdominal bloating and fatigue. Other symptoms include breast swelling and pain ( masto-dynia ), headache, acne, digestive upset, dizziness, sensitiv-ity to external stimuli, and hot flushes. The most common behavioral symptom is emotional lability. Other behavioral symptoms include irritability, depressed mood, anxiety, hostility, lachrymosity, increased appetite, difficulty con-centrating, and changes in libido. Box 39.1 presents the diagnostic criteria for PMDD as described in the DSM-IV. Box 39.2 lists the diagnostic criteria for PMS. The criteria for the diagnosis of PMDD are more rigorous than those of PMS and emphasize the existence of mood-related symp-toms. PMS can be diagnosed on the basis of either mood or physica...

  TREATMENT   The prospective charting of symptoms not only documents the cyclic or noncyclical nature of the patient’s symptoms, but also allows her to play a key role in the diagnostic and management team. This will allow her to regain some con-trol of her symptoms. For some women, providing a diag-nostic label helps relieve the fear that they are “going crazy.” Often a patient’s symptoms become more bearable as she gains insight. The symptom calendar is usually con-tinued during the treatment phase to monitor the effec-tiveness of treatment and to suggest the need for further focused therapy.   Nonpharmacologic Treatment   Diet recommendations emphasize eating fresh rather than processed foods. The patient is encouraged to eat more fruits and vegetables and minimize refined sugars and fats. Minimizing salt intake may help with bloating, and eliminat-ing caffeine and alcohol from the diet can reduce nervous-ness and anxiety. None of these therapies have shown stati...